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APPLICATION FOR WELLIPUMP PERMIT,-) ' SAN JOAQUIN COUNTY PUBLIC HEALTH SEA' ENVIRONMENTAL HEALTH DIVISION �OLJ P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. C 95 A 201 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1_YEAR_FROM DATE ISSUED 1Comploto in Trlplleatol APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAL• JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTERS-11 X115.3 AND THE THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AOO52 RESSIOR APN# ! ? IN C-8 f CDT �jG PARCEL SIZElAPN1�� OWNER'S NAME. �l/lam/ f., ,,.. ADDRESS !© W{.±a 1 �✓(i !SWR./ "PHONE I CONTRACTOR :LL ADDRESSVT F,th4jAjy-jn UCj3 PHONE 8U6 CONTRACTOR ADDRESS LIC# PHONE# TYPE OF.WELUlPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL it ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ,/ I ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p { {TYPE OF PUMP, ❑ OUT•OF- RRVVICE WELL GEOPHYSICAL WELL , ❑ SOIL BORING fd9D/ESTRUCTION: Pilo Sha Sp4 ZOO 1t g r INUSE _TYPE.OF WELL CONSTRUCTION SPECIFICATIONS A I ❑ INDUSTRIAL ❑OPEN BOTTOM DFA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEEUPVC DIA.OF WELL CASINO D ❑ PUBUC/MUNICIPAL ©DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIOATIONIAG ❑OTHER GAOLIT BEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Y. ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S� ' PROPOSED CONSTRUCTIONIDPoWNO METHOD: MUD ROTARY AIR ROTARY AVGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND f REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I S NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTiFIE6 THE FOLLOWING; CE IFY T T IN PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNI AN M 6 C 24 S IN ADVANCE FOR ALL REQUIRED INS r'ECTIONS AT f20014411104422. COMPLETE DRAWING AT LOWER AREA PROM O 6lSnad X - U CL&(it tiV`&I ,,.. 7 Title _ Date PLOT PLAN IDrtwv to Bosis)Seale 'to lf,f I. NAMES OF STREETS OR ROADS NEAREST TO OR HOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION Of SEWAGE DI6POSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIVS OF 09E HUNDRED FIFTY FT. i STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPEATY. <..,.., i......... ', .....E ,,-.,_:'_..:. ..L... .,:'....: ' ' ....-. V w ..: . .. ., e-,:I r l .R 1 {{ 1 :,.. JUL -6-3996 :- .... .. .. ....,. . �,8.N:.�L1rnr�IL:i�,i ...1 ' .. ., ........ - w�11HEALTH:SEkV{G . ...:.. NII R A�`EN-AL HE H OM&D'. : ,.. . ...>.. s • : t � _ DEPARTMENT USE ONLY Application Accepted By� Grout Inspection By Date Pump inspection By �'7 pate Destruction Inspection By Date t -q 4 Comments: IO t 12 s f/i� 21443, M.S+-.r Ag 166 77 ACCOUNTING ONLY: AIDE FAC# PE CODES FEE INFO AMOUNT REMITTED CHEC CASH RECEIVED BY DATE PERMITMIERVICE REQUEST NUMNER INVOICE 1' (A ,, 0 ala